Provider Demographics
NPI:1821278193
Name:PRIMARY CARE CLINIC OF JACKSON, P.C.
Entity Type:Organization
Organization Name:PRIMARY CARE CLINIC OF JACKSON, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAHIR
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-327-9700
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-1599
Mailing Address - Country:US
Mailing Address - Phone:269-327-9700
Mailing Address - Fax:269-327-9701
Practice Address - Street 1:2218 SUGARLOAF AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-6771
Practice Address - Country:US
Practice Address - Phone:269-327-9700
Practice Address - Fax:269-327-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITA065207207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3397804Medicaid
MI0M49360Medicare PIN